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Acute Care Nurse Practitioner Practice: Results of a 5-Year Longitudinal Study Ruth M. Kleinpell

Am J Crit Care 2005;14:211-219

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CE Article

ACUTE CARE NURSE PRACTITIONER PRACTICE: RESULTS OF A 5-YEAR LONGITUDINAL STUDY By Ruth M. Kleinpell, RN-CS, PhD, ACNP. From Rush University College of Nursing and Our Lady of the Resurrection Medical Center, Chicago, Ill.

The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed. (American Journal of Critical Care. 2005;14:211-221)

CE

Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: 1. Describe the progression of participants involved in this acute care nurse practitioner (ACNP) study of practice 2. Recognize the manner in which the ACNP role has evolved over the 5 years studied 3. Understand outcomes measured and influenced by ACNP practice

I

n the newest subspecialty area of nurse practitioner practice, acute care nurse practitioners (ACNPs) provide advanced nursing care to patients with complex acute, critical, and chronic health conditions.1 The role and the scope of practice of ACNPs continue to expand. Originally described as a role suited for nurses who managed complex issues of patients’ care in high-acuity settings, most often in intensive care units (ICUs), the role of the ACNP has

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broadened in capacity. ACNPs work in traditional settings, including acute and critical care inpatient settings, and in nontraditional care settings such as specialty-based clinics and private practice groups.2,3 However, although ACNPs are acknowledged members of acute care teams, uncertainty about the role of ACNPs persists.

ACNPs are primarily involved in direct

care of patients with acute and critical illness.

Background and Overview In order to gather information about the developing role of ACNPs, a survey research study 4 was begun in 1996 with the first group of nurse practitioners who took the national ACNP certification examination. Results from this first survey of 125 practitioners indicated that ACNPs practice in tertiary and secondary healthcare settings, including unit-based areas, urgent-care centers, and multipractice clinics. Predominant role components reflected nurse practitioners’ focus on obtaining histories and conducting physical examinations, prescribing treatments, and initiating transfers and consultations. Although a vari-

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ety of invasive therapeutic procedures were being performed by the ACNPs, the 3 most frequent aspects of care were discussing care with patients’ family members, ordering laboratory tests and interpreting the results, and initiating discharge planning—all evidence of the integrative nature of the ACNP role. The survey research was then extended to include the first 3 groups that obtained national ACNP certification. In this study5 of 384 ACNPs, aspects of practice were explored further, including specialty area work settings, major components of the ACNP role, hours worked, salary structures, and work satisfaction levels. The survey results revealed that ACNP practice was expanding to a variety of specialty-based settings, including step-down units, units without house staff coverage, and oncology, transplant, cardiology, and radiology units, among others. Roles were often specialty based, collaborative practice, or unit based. Although most ACNPs were involved in direct management of patients’ care, additional tasks such as teaching, research, program development, staff education, and administrative responsibilities such as committeebased involvement were evolving aspects of the role of these practitioners. The survey research was then extended to the first 6 groups to obtain national ACNP certification (n = 740), with follow-up on a yearly basis. Longitudinal results from year 1 (n = 619) revealed continued growth of the role of ACNPs.6 Participants also began to identify implications for ACNP educational programs and suggestions for those contemplating pursuing an ACNP position. Study results from year 2 (n = 545) indicated further development of ACNP practice. 7 Issues in practice, including the benefits of being an ACNP, resources for role development, and role changes were highlighted. Yearly follow-up surveys were then conducted for year 3 (n = 530), year 4 (n = 465), and year 5 (n = 437) with the respondents remaining in the longitudinal study (64% cumulative response rate). In order to compare the roles and practice profiles of ACNPs who obtained certification in the first years it became available, an additional survey was conducted in 2001 with all ACNPs certified from 1998 through July 2000 (n = 1027). This comparison group (n = 743; 72% response rate) highlighted additional changes in the ACNP role. The cumulative results of the national longitudinal ACNP survey are described in the following material.

Study Methods A survey with 44 questions on role aspects, practice components, and role changes after certification 212

Table 1 Longitudinal survey of acute care nurse practitioners: response rates Year

No. of responses

Annual response rate, %

Initial

740 of 952

78

1

619 of 740

84

2

545 of 619

88

3

530 of 545

97

4

465 of 530

85

5

437 of 465

94

as an ACNP was mailed annually to participants who had responded to the preceding year’s survey. The survey addressed characteristics of practice settings, role responsibilities, and aspects of practice, including credentialing and privileging status, frequently performed procedures, work requirements, role changes, and plans for employment. Each year, an additional aspect of practice was assessed, including negotiation of benefits, recommendations for practitioners, recommendations for educators, and outcome evaluation. Second mailings were sent to ACNPs who had not responded within 4 weeks of the first mailing.

Results During the 5-year study period, responses were consistently received from 437 participants. Annual response rates ranged from 78% to 97%, with an overall response rate of 86% (Table 1). Most respondents were women (95%), 29 to 63 years old (mean 43.13 years) (Figure 1) and white (95%). Most worked full time in the ACNP position (Figure 2). National geographic distribution of the participants is depicted in Figure 3. Organizational affiliations included teaching hospitals, acute care and community hospitals, and clinic settings (Table 2). Most ACNPs reported practicing in tertiary care practice settings including ICUs, with 20% to 26% in coronary ICUs, 14% to 18% in surgical ICUs, 17% to 19% in cardiothoracic ICUs, 13% to 16% in medical ICUs, 6% to 8% in neurological ICUs, 5% to 8% in trauma ICUs, and 3% to 4% in transplant ICUs. Other specialty areas of practice included emergency care (9%-12%), oncology (7%-8%), multipractice clinic (5%-8%), and pediatric (1%-2%) settings. Consistently throughout the 5 years of the longitudinal survey, nearly 50% of respondents did not identify a traditional ICU or an urgent/acute care practice setting, but acknowledged a growing number of practice sites. Table 3 outlines the various practice sites reported by practitioners during the 5-year study.

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56-60 >60 29-35

Pacific

West

51-55

36-40

Northeast

South Central North Central

46-50

Southeast 41-45

Figure 1 Distribution of respondents’ ages in years (mean, 43.13 years).

Figure 3 Geographic distribution of participants.

Table 2 Work settings of acute care nurse practitioners*

Part time

No. (%) of respondents Setting Full time

Figure 2 Hours per week spent working as an acute care nurse practitioner.

Most ACNPs practice in tertiary care

practice settings, although nearly 50% did not list intensive care or acute care practice sites, indicating the expansion of the ACNP role. Unit-based roles remain an option for practice, with 10% of practitioners continuing to report this type of role. Both specialty-based (increasing from 37% in year 1 to 49.5% in year 5) and collaborative practice roles (increasing from 17% in year 1 to 25% in year 5) have become more popular options for ACNP practice. The main focus of ACNPs is direct management of patients’ care, with 85% to 88% of time spent on that responsibility. Table 4 lists other aspects of the role reported by respondents, including teaching, research, program development, quality assurance, and administrative components. Most practitioners reported that they were credentialed (81%-86%) and had privileges (79%-84%). Most received their credentials and privileges through the medical staff off ice (69%-83%) or from the department of nursing (8%-12%) or human resources (2%-4%). Credentials were received through the medical staff office (69%-83%), department of nursing (8%-12%), or human resources (2%-4%). Most respondents received practice privileges from the department of medicine or medical staff office (79%-84%) or an allied health department (11%-13%).

Year 1 Year 2 Year 3 Year 4 Year 5 (n = 445) (n = 396) (n = 384) (n = 333) (n = 321)

Teaching hospital

204 (46)

178 (45)

181 (47)

159 (48)

155 (48)

Physician group

104 (23)

97 (24)

100 (26)

80 (24)

76 (24)

Acute care general hospital

20 (4)

16 (4)

30 (8)

23 (7)

15 (5)

Community hospital

19 (4)

19 (5)

16 (4)

17 (5)

11 (3)

Clinic/health maintenance organization

15 (3)

12 (3)

10 (3)

8 (2)

7 (2)

*Numbers in columns may not total n at the top of column because some responses were for other settings not listed in this table.

Components of the ACNP position that were identified included gathering medical histories and performing physical examinations, conducting rounds, writing orders, interpreting results of laboratory and diagnostic tests, performing procedures, providing education, consulting, and doing discharge planning. Table 5 lists the activities and procedures that ACNP respondents reported performing. Mean salaries for ACNPs ranged from $59 590 in year 1 to $72 408 in year 5, with the top of the range as high as $130 000. The importance of negotiating salary and benefits for the ACNP position was a common anecdotal comment.

Respondents emphasized the importance of negotiating for salary and benefits. Reports of respondents’ satisfaction with the ACNP role are summarized in Tables 6 and 7. Critiques

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Table 3 Practice settings of acute care nurse practitioners Tertiary care, intensive care units Cardiothoracic Coronary Medical Neurological Surgical Transplant

Table 4 Responsibilities respondents listed as being part of their role as an acute care nurse practitioner No. of respondents Year 1 Year 2 Year 3 Year 4 Year 5 Responsibility (n = 445) (n = 396) (n = 384) (n = 333) (n = 321) 83

123

96

82

86

Teaching

168

257

160

138

131

Research

94

150

95

86

75

Tertiary care, emergent/acute care settings Emergency Step-down/telemetry Trauma Urgent care

Program development

88

119

72

73

49

Quality assurance

80

123

73

75

65

Specialty tertiary care Bone marrow transplantation Electrophysiology Internal medicine Interventional cardiology Neurology Oncology Orthopedics Pediatrics Presurgical testing/preanesthesia Pulmonary Radiology

Department projects

99

13

85

80

69

Clinic settings Allergy Cardiology Endocrinology Ear, nose, and throat/plastic surgery Family practice Gastroenterology Geriatrics Infectious disease Internal medicine Multipractice Nephrology Pain management Pulmonary medicine Rheumatology Wound care Other Correctional facility Dialysis center Employee health Heart transplant program Holistic medicine Home care Hospitalist service Long-term care Medical flight program Mental health Metabolism/genetics Occupational medicine Rehabilitation and physical medicine Subacute care Sports medicine

of the role are provided in Table 8, and aspects of change in the ACNP role are listed in Table 9. 214

Administrative

Numbers reflect those participants indentifying each responsibility as part of their role as an acute care nurse practitioner.

In years 3 through 5 of the study, participants were asked to rate the degree of impact they were making in their role as an ACNP on several outcome measures and were asked whether they were assessing outcomes of practice. The results are summarized in Table 10. The number of survey respondents who reported that they were not currently working in an ACNP position remained constant throughout the study at 20% to 22% each year. Reasons for not being employed as an ACNP are summarized in Table 11.

Discussion Although ACNPs were originally envisioned to function primarily in ICUs and high-acuity settings, the role of these practitioners has expanded dramatically. As the results of this 5-year national study reflect, the practice settings of ACNPs are diverse. By virtue of educational preparation and national certification, ACNPs focus their care on patients with acute and critical illnesses. However, as the traditional boundaries of acute and critical care have extended beyond the hospital setting, so too have the opportunities for ACNP practice. Newly developed competencies of ACNPs highlight key aspects of the role, including assessment and diagnosis of health status, management of acute illness states, and performance of interventions and diagnostic strategies to promote stability. The competencies also address other aspects of the advanced practice nursing role such as teachingcoaching and ensuring quality care.8 As highlighted in this study, ACNPs are practicing in a wide variety of practice settings. Although ICU and specialty acute care tertiary settings are areas where a significant number of ACNPs practice, the list of unique practice settings continues to grow.

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Table 5 Activities and procedures performed by acute care nurse practitioners No. (%) of respondents* Year 1 (n = 445)

Activity

Year 2 (n = 396)

Year 3 (n = 385)

Year 4 (n = 334)

Year 5 (n = 320)

Discuss care issues with patients’ family members

418 (94)

388 (98)

372 (97)

327 (98)

307 (96)

Order and interpret routine clinical laboratory tests

427 (96)

384 (97)

375 (97)

330 (99)

306 (96)

Order and interpret radiographs

405 (91)

368 (93)

355 (92)

313 (94)

297 (93)

Initiate specialty consultation

387 (87)

360 (91)

356 (92)

313 (94)

300 (94)

Interpret 12-lead electrocardiograms

387 (87)

329 (83)

319 (82)

279 (84)

259 (81)

Initiate discharge planning

374 (84)

332 (84)

304 (79)

298 (89)

263 (82)

356 (80) 334 (75)

277 (70)

264 (82)

289 (73)

308 (80) 291 (76)

275 (82)

Examine and clean wounds

254 (76)

223 (70)

Obtain samples for culture

325 (73)

285 (72)

287 (74)

252 (75)

218 (68)

Institute blood component therapy

303 (68)

329 (83)

257 (67)

233 (70)

222 (69)

Give nursing in-service training

257 (65)

261 (68)

241 (72)

215 (67)

Initiate and adjust nutritional feedings

238 (60)

223 (58)

203 (61)

168 (52)

206 (54)

193 (58)

167 (52)

Institute and adjust intravenous infusion rates

Manage resuscitative efforts Initiate and adjust vasoactive intravenous infusions

210 (53)

200 (52)

177 (53)

162 (51)

Perform defibrillation

206 (52)

211 (56)

189 (57)

165 (52)

211 (56)

190 (58)

169 (53)

Insert nasogastric feeding tubes Apply local anesthetics

198 (50)

196 (52)

169 (51)

151 (47)

Pack wounds

194 (49)

190 (50)

171 (52)

151 (47)

Perform wound care and debridement

186 (47)

187 (49)

162 (49)

145 (45)

Initiate quality improvement/quality assurance study

154 (39)

147 (37)

139 (42)

128 (40)

Initiate use of muscle relaxants

151 (38)

181 (48)

156 (47)

139 (43)

Manage patients receiving mechanical ventilation

139 (35)

128 (34)

122 (37)

101 (32)

Perform routine incisions and drainage

131 (33)

144 (38)

126 (38)

111 (35)

Perform cardioversion

127 (32)

138 (36)

118 (35)

105 (33)

Suture superficial lacerations

115 (29)

124 (33)

96 (29)

92 (29)

Initiate and adjust mechanical ventilation

108 (29)

109 (33)

90 (28)

Adjust temporary pacemaker settings

104 (28)

102 (31)

87 (27)

Manipulate pulmonary artery catheter

88 (24)

88 (26)

76 (24)

81 (22)

64 (19)

61 (19)

69 (21)

61 (19)

75 (19)

78 (21) 67 (18)

58 (17)

57 (18)

63 (16)

65 (17)

59 (18)

58 (18)

40 (10)

41 (11)

29 (9)

28 (9)

44 (11)

44 (12)

50 (15)

42 (13)

44 (12)

46 (12)

29 (9)

30 (9)

44 (11)

37 (10)

34 (10)

28 (9)

44 (11)

44 (12)

32 (10)

12 (3)

9 (11)

8 (2)

29 (9) 4 (1)

99 (25)

Initiate use of central venous catheters

93 (21)

Initiate use of arterial catheters

85 (19)

Remove intracardiac catheters Initiate use of peripheral intravenous catheters Perform needle thoracentesis

53 (12)

Adjust settings on cardiac assistive devices Perform lumbar punctures

49 (11)

Perform endotracheal intubations Insert pulmonary artery catheters Remove chest tubes

40 (9)

75 (19)

continued

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Table 5 continued Year 1 (n = 445)

Activity

Year 2 (n = 396) 6 (2)

Aspirate/harvest bone marrow 36 (8)

Insert chest tubes

No. (%) of respondents* Year 4 Year 3 (n = 334) (n = 385)

Year 5 (n = 320)

8 (10)

4 (1)

33 (9)

25 (8)

9 (3) 23 (7)

Administer chemotherapy

24 (6)

26 (7)

16 (5)

20 (6)

Insert thoracostomy tubes

20 (5)

24 (6)

19 (6)

17 (5)

Adjust medications

5 (6)

Remove sheaths

5 (6)

1 (1)

4 (1)

2 (1)

Perform paracentesis

20 (5)

2 (2)

2 (1)

2 (1)

Perform and interpret stress tests

20 (5)

1 (1)

3 (1)

Perform suprapubic bladder aspiration

12 (3)

10 (3)

4 (1)

Perform cutdowns Remove intra-aortic balloon pumps

12 (3) 8 (2)

7 (2) 2 (2)

6 (2) 6 (2)

4 7 7 4

2 (2)

2 (1)

3 (1)

Perform exercise and pharmacological stress testing Obtain skin biopsy specimens

4 (1)

2 (2)

(1) (2) (2) (1)

5 (2)

*Missing data in the column for year 1 are activities identified in a subsequent year; missing data for years 2 to 5 indicate that no respondents identified that activity.

ACNP roles have also evolved with respect to type of practice, with increases in specialty-based (from 37% in year 1 up to 49.5% in year 5) and collaborative practice roles (from 17% in year 1 up to 25% in year 5), but unit-based roles remaining constant (10%). The primary responsibilities of ACNPs remain those related to direct management of patient care. Although a number of other subroles have evolved, including education, quality initiatives, and research, the focus of the role is direct management of patient care, reported to account for 85% to 88% of time spent in the role. The most frequent aspects of the ACNP position are conducting physical examinations, gathering patients’ medical histories, writing orders, conducting rounds, initiating transfers and consultations, and preparing patients for discharge. Discussing patients’ care with the patients’ family members, ordering laboratory and radiological tests and interpreting the results, initiating consultations, and initiating discharge planning have remained the top 5 frequently performed activities of ACNPs. The focus of ACNP practice is not the performance of work involving invasive skills, a common misperception among those unfamiliar with the role. Performance of tasks involving invasive skills depends on job descriptions, patients’ acuity, and collaborative practice agreements. The role aspects identified by the practitioners who responded to the surveys highlight that coordination of care is a major role of ACNPs.

216

A common misperception is that the

focus of ACNP practice is work involving invasive skills.

Salaries of ACNPs have increased, and although the information on the national salary base of ACNPs is of interest, salaries are negotiated on an individual basis and often also depend on job responsibilities (eg, whether on-call time is required) and the experience of the individual practitioner (eg, nursing experience, experience as an ACNP). Negotiation of benefits aside from base salary (eg, conference attendance to meet requirements for continuing education, journal subscriptions, malpractice insurance) and bonus structures (eg, profit sharing, productivity-based structure) are additional aspects to consider, as cited by survey respondents. ACNPs continue to report satisfaction in the role and with their collaboration with physicians, citing autonomy, involvement with patients and patients’ care, and collaboration as advantages of the role. However, some practitioners also continue to cite that lack of recognition and not being considered a professional peer are disadvantages in the role. Often, such problems stem from inadequate knowledge of the role of ACNPs or the capabilities of ACNP practitioners. Publicizing the role of ACNPs is a continued requirement to secure identification of the role. On-line

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Table 6 Satisfaction of acute care nurse practitioners with their current positions No. (%) of respondents Year 1 Year 2 Year 3 Year 4 Year 5 Level of satisfaction (n = 445) (n = 400) (n = 386) (n = 340) (n = 318)

Table 8 Critiques of the role of acute care nurse practitioners Advantages

Disadvantages

Autonomy in the role

Lack of recognition

Patient involvement/ advocacy

Not considered professional peer

Very satisfied

218 (49)

202 (51)

194 (50)

189 (55)

178 (56)

Impacting patients’ outcomes

Somewhat satisfied

187 (42)

162 (41)

158 (41)

127 (37)

115 (36)

Collaborative care

Somewhat dissatisfied

36 (8)

32 (8)

25 (6)

19 (6)

19 (6)

Very dissatisfied

4 (1)

4 (1)

9 (2)

5 (1)

6 (2)

Salary Hours/schedule

Table 9 How the role of acute care nurse practitioners has changed since it was established Increased autonomy in the role Expansion of practice and role Trust and respect from physicians and staff

Table 7 Reports of acute care nurse practitioners’ satisfaction with degree of collaboration with physicians No. (%) of respondents Year 1 Year 2 Year 3 Year 4 Year 5 Level of satisfaction (n = 444) (n = 397) (n = 386) (n = 341) (n = 317) Very satisfied

271 (61)

242 (61)

245 (63)

232 (68)

212 (67)

Somewhat satisfied

138 (31)

123 (31)

109 (28)

85 (25)

86 (27)

Somewhat dissatisfied

22 (5)

28 (7)

21 (5)

18 (5)

13 (4)

Very dissatisfied

13 (3)

4 (1)

11 (3)

6 (2)

6 (2)

searches with the term “acute care nurse practitioner” yield only 53 citations in Ovid MEDLINE and Cumulative Index to Nursing and Allied Health (December 28, 2004). These citations are a mix of articles describing aspects of ACNP education, program development, and practice. A more general search on info.com, a Web engine that combines 14 search engines including Google, Ask Jeeves, Yahoo, AltaVista, Overture, Inktomi, LookSmart, Overture, and Open Directory, resulted in 61 “hits,” most of which are descriptions of ACNP education programs. Much work remains to promote the role of ACNPs, and all practitioners can be influential in educating healthcare providers, legislators, and the public on aspects of ACNP practice.

Advantages of being an ACNP include autonomy, involvement with patients and their care, and opportunities for collaboration.

Increase in confidence, skills, and knowledge

Affecting patients’ outcomes was identified as an advantage of being an ACNP. Participants report that they are making a fairly high impact on outcomes, including length of stay, costs, readmission rates, adherence to best practices, medical management, complications, resource utilization, continuity of care, patients’ access to care, patients’ satisfaction, and education of patients, patients’ family members, and staff. The monitoring of outcomes of ACNP practice is a priority and is essential for further advancing the role. By assessing the outcomes of ACNP practice, the benefits of the role can be demonstrated. Existing research data provide support for the contention that ACNPs provide high-quality, cost-effective care and promote beneficial outcomes for patients in a variety of settings. Recent research indicates that ACNP care results in beneficial care, including decreasing length of stay9-11 (M. J. Cowan, M. Shapiro, R. D. Hays, A. Afifi, S. Vazirani, S. L. Ettner, unpublished data, 2005); decreased costs of care9-11; decreased rates of urinary tract infection and skin breakdown10; compliance with clinical practice guidelines, including deep vein thrombosis/ pulmonary embolus prophylaxis, stress bleeding prophylaxis, and anemia12; management of patients receiving mechanical ventilation13; enhanced communication and collaboration14; and continuity of care.15 Yet only selected aspects of ACNP practice have been examined. Respondents in this study reported a significant increase in the percentage of ACNPs who assess outcomes of practice. The results of those efforts should be published and disseminated because the existing research focused on the role of ACNPs is insufficient, especially when various types of practice settings and specialty roles that exist are considered.

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Table 10 Outcomes of acute care nurse practitioner practice Percentage of respondents assessing outcome measures Degree of impact (low to high on scale of 1 to 5)

Year 3

Year 5

↓ Length of stay

3.72

24

49

↓ Health care costs

3.60

20

49

↓ Readmission rates

3.97

22

48

↑ Adherence to best-practice guidelines

4.12

16

45

Improve medical management

3.87

17

44

↓ Complications

3.48

18

52

↓ Resource utilization

4.34

13

42

↑ Continuity of care

4.51

22

39

↑ Patients’ access to care

4.01

26

42

↑ Patients’ satisfaction

4.51

19

56

↑ Patients’ education

4.52

16

46

↑ Education of patients’ families

4.46

16

42

↑ Staff education

3.83

15

40

Outcome measure

Table 11 Chief reason not employed as an acute care nurse practitioner No. of respondents Year 1 Year 2 Year 3 Year 4 Year 5 (n = 165) (n = 143) (n = 140) (n = 118) (n = 114)

Reason Seeking employment

61 (37)

27 (18)

13 (9)

9 (8)

5 (4)

Seeking other employment

2 (1)

0 (0)

2 (1)

3 (2)

0 (0)

15 (9)

19 (13)

25 (18)

15 (13)

24 (21)

Family responsibilities

7 (4)

5 (3)

5 (4)

3 (3)

2 (2)

Working in another position

0 (0)

46 (31)

58 (41)

61 (52)

61 (54)

80 (49)

46 (31)

37 (26)

27 (23)

22 (19)

Child care

Other

ACNPs provide high-quality, cost-

effective care and promote beneficial outcomes for patients in a variety of settings.

On average, 20% of those certified as ACNPs reported that they were not currently practicing as ACNPs. Although various reasons were listed, including working in another position, seeking employment, and family and child care responsibilities, this trend 218

remains important to monitor. Of significance is that the number of ACNPs seeking positions during the 5 years of the study has decreased substantially. In year 1 of the study, 61 (37%) reported they were currently seeking employment; that number declined to 27 (18% ) in year 2, 13 (9%) in year 3, 9 (8%) in year 4, and 5 (4%) in year 5. When the ACNP role first evolved, finding a position was challenging in some demographic areas that were saturated with ACNP educational programs or in areas where the role was not recognized as a new area of advanced practice nursing. Nationally, advertised positions for ACNPs are now common, as recognition of the role has evolved.

Summary This longitudinal study provides information on aspects of practice of ACNPs and the development of the role of ACNPs from a national perspective. The data provided by more than 400 ACNPs provides important information on the role of these practitioners and on the development of the role during the 5year study period. Study limitations include attrition over the longitudinal study time and limited geographic representation from the West, Pacific, and South Central parts of the United States. Additional study of the ACNP role and outcomes of practice are needed. This study is the largest study of ACNP practice to date and has provided beneficial information to

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ACNP practitioners, educators, and students. The information has also been useful to physician collaborators and administrators, who have astutely identified that the ACNP role holds much potential for meeting the healthcare needs of acutely and critically ill patients. ACKNOWLEDGMENTS Research funding from the American Association of Critical-Care Nurses, the American Nurses Foundation, Alpha and Gamma Phi chapters of Sigma Theta Tau, and Rush University College of Nursing is gratefully acknowledged. Commentary by Mary Jo Grap (see shaded boxes). REFERENCES 1. American Nurses Association. Standards of Clinical Practice and Scope of Practice for the Acute Care Nurse Practitioner. Washington, DC: American Nurses Publishing; 1995. 2. Hravnak M, Kleinpell R, Magdic K, Guttendorf J. The acute care nurse practitioner. In: Hamric AB, Spross JA, Hanson CM, eds. Advanced Practice Nursing: An Integrative Approach. New York, NY: Elsevier Science; 2005:475-514. 3. Kleinpell RM, Hravnak M. The acute care nurse practitioner. In: Crabtree MK, Pruitt R, eds. Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education. Washington, DC: National Organization of Nurse Practitioner Faculties. 2002:113-126. 4. Kleinpell RM. Acute-care nurse practitioners: roles and practice profiles.

AACN Clin Issues. 1997;8:156-162. 5. Kleinpell RM. Reports of role descriptions of acute care nurse practitioners. AACN Clin Issues. 1998;9:290-295. 6. Kleinpell-Nowell R. Longitudinal survey of acute care nurse practitioner practice: year 1. AACN Clin Issues. 1999;10:515-520. 7. Kleinpell-Nowell R. Longitudinal survey of acute care nurse practitioner practice: year 2. AACN Clin Issues. 2001;12:447-452. 8. National Panel for Acute Care Nurse Practitioner Competencies. Acute Care Nurse Practitioner Competencies. Washington, DC: National Organization of Nurse Practitioner Faculties; 2004. 9. Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31:2752-2763. 10. Russell D, VorderBruegge M, Burns SM. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care. 2002;11:353-364. 11. Miers S, Meyer L. Effect of cardiovascular surgeon and ACNP collaboration on postoperative outcomes. AACN Clin Issues. 2005;16:149-158. 12. Garcias VH, Sicoutris CP, Meredith DM, et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in the surgical intensive care unit [abstract]. Crit Care Med. 2003;31:12. Abstract 93. 13. Hoffman LA, Tasota FJ, Zullo TG, Scharfenberg C, Donahoe MP. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14:121-132. 14. Vazirani S, Hays RD, Shapiro MF, Cowan M. Effect of a multidisciplinary intervention on communication and collaboration among doctors and nurses. Am J Crit Care. 2005;14:71-77. 15. Hoffman LA, Happ MB, Scharfenberg C, DiVirglio-Thomas D, Tasota F. Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners. Am J Crit Care. 2004:13:480-488.

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AMERICAN JOURNAL OF

CE

CRITICAL CARE

®

CE Test Instructions To receive CE credit for this test (ID# A051403), mark your answers on the form below, complete the enrollment information, and submit it with the $12 processing fee (payable in US funds) to American Association of Critical-Care Nurses (AACN). Answer forms must be postmarked by May 1, 2007. Within 3 to 4 weeks of AACN receiving your test form, you will receive an AACN CE certificate. This continuing education program is provided by AACN, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation. AACN has been approved as a provider of continuing education by the State Boards of Nursing of Alabama (#ABNP0062), California (01036), Florida (#FBN2464), Iowa (#332), Louisiana (#ABN12), Nevada, and Colorado. AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

ID#: A051403

Form expires: May 1, 2007 Contact hours: 2.0 Passing score: 9 correct (75%) Test writer: Kimberly Brown, RN, MSN, CS-FNP Category: A Test Fee: $12

CE Test Form ACUTE CARE NURSE PRACTITIONER PRACTICE: RESULTS OF A 5-YEAR LONGITUDINAL STUDY Objectives

1. Describe the progression of participants involved in this acute care nurse practitioner (ACNP) study of practice 2. Recognize the manner in which the ACNP role has evolved over the 5 years studied 3. Understand outcomes measured and influenced by ACNP practice Mark your answers clearly in the appropriate box. There is only one correct answer. You may photocopy this form.

1. ❑a ❑b ❑c ❑d

2. ❑a 3. ❑a ❑b ❑b ❑c ❑c ❑d ❑d

4. ❑a ❑b ❑c ❑d

5. ❑a ❑b ❑c ❑d

6. ❑a ❑b ❑c ❑d

7. ❑a ❑b ❑c ❑d

9. ❑a 10. ❑a 11. ❑a 12. ❑a 13. ❑a 14. ❑a 15.❑a ❑b ❑b ❑b ❑b ❑b ❑b ❑b ❑c ❑c ❑c ❑c ❑c ❑c ❑c ❑d ❑d ❑d ❑d ❑d ❑d ❑d Name

Program evaluation Objective 1 was met Objective 2 was met Objective 3 was met The content was appropriate My expectations were met This method of CE is effective for this content

8. ❑a ❑b ❑c ❑d

Agree ❑ ❑ ❑ ❑ ❑ ❑

Neutral ❑ ❑ ❑ ❑ ❑ ❑

Disagree ❑ ❑ ❑ ❑ ❑ ❑

Address City

State

ZIP

E-mail address AACN member number I would like to receive my certificate via e-mail (check box) ❑

The level of difficulty of this test was: ❑ easy ❑ medium ❑ difficult To complete this program, it took me hours/minutes.

Mail this entire page to: AACN, 101 Columbia, Aliso Viejo, CA 92656, (800) 899-2226 220

AMERICAN JOURNAL OF CRITICAL CARE, May 2005, Volume 14, No. 3

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CE Test Questions ACUTE CARE NURSE PRACTITIONER PRACTICE: RESULTS OF A 5-YEAR LONGITUDINAL STUDY 1.

The initial survey research study investigating the role of the acute care nurse practitioner (ACNP) in 1996 gathered information from which group of participants? a. 300 graduates from ACNP programs in the United States b. 125 nurse practitioners who took the first national ACNP certification examination c. 385 ACNPs practicing in tertiary healthcare settings d. 67 nurse practitioners teaching in accredited ACNP programs in the United States

2.

Which of the following is 1 of the 3 aspects of care most frequently delivered by this first survey group? a. Discussing care with patients’ family members b. Airway intubation c. Central venous catheter insertion d. Bone marrow aspiration

3.

In a survey including the first 3 groups that obtained national ACNP certification, which of the following was found to be true? a. ACNP practice was expanding to a variety of specialtybased settings b. ACNPs solely functioned in direct patient management tasks c. The primary aspect of care delivered by ACNPs was performing invasive therapeutic procedures d. Staff education and administrative responsibilities were not included in the role

4.

5.

6.

Initially, 740 certified ACNPs were contacted to be participants in the 5-year longitudinal study. How many participants consistently responded during the 5-year period? a. 619 b. 740 c. 465 d. 437 Where are most ACNPs involved in the study of practice located? a. Pacific Northwestern United States b. Southeastern United States c. Northeastern United States d. Northern Central United States In all years of the study, which of the following is not included as 1 of the 5 activities most frequently performed by ACNPs? a. Ordering laboratory and radiographic tests b. Gathering patients’ medical histories c. Performing rounds d. Initiating use of a central venous catheter

7.

Which of the following is true of ACNP salaries during years 1 through 5? a. Salaries decreased during the 5-year study period. b. Salaries were usually negotiated on an individual basis. c. Salaries were calculated independent of job responsibilities. d. Salaries were determined independent of practitioner experience.

8.

Which of the following is true regarding satisfaction with the ACNP role among the study participants? a. Satisfaction with the ACNP role decreased during the study period. b. Autonomy, involvement with patients’ and their families, and collaboration are primary advantages of the ACNP role. c. Lack of recognition is not considered a disadvantage of the ACNP role. d. Working under the close supervision of physicians increased role satisfaction.

9.

What recommendation is made by the author to promote the role of ACNPs? a. Publicizing the role of ACNPs is a continued requirement to increase identification of the role b. Increasing ACNP graduate programs on the West Coast c. Encouraging ACNP practice settings outside of the tertiary healthcare arena d. Promoting the role internationally

10. What percentage of those studied are not currently practicing as ACNPs? a. 10% b. 40% c. 20% d. 5% 11. Which of the following patient care outcomes has not been demonstrated by ACNP practice? a. Decreased length of stay b. Increased patient satisfaction c. Decreased readmission rates d. Increased inpatient cost of care 12. Which of the following is true regarding the number of ACNPs seeking a position during the course of the study? a. The number of ACNPs seeking positions decreased substantially during the course of the study b. The number of ACNPs seeking positions increased substantially during the course of the study c. The number of ACNPs seeking positions remained unchanged during the course of the study d. The number of ACNPs seeking employment in rural areas increased during the course of the study

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Acute care nurse practitioner practice results of a 5 year longitudinal study  
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